A nurse is preparing to perform a venipuncture to collect a blood sample from an infant.
Which of the following restraints should the nurse plan to use for this procedure?
Jacket
Mitten
Mummy
Elbow
The Correct Answer is C
Choice A rationale
Jacket restraints are typically used to secure a child’s arms during procedures. They are not specifically designed for venipuncture in infants.
Choice D rationale
Elbow restraints are used to secure the child’s elbows, often during procedures involving the upper body. They are not typically used for venipuncture.
Choice B rationale
Mitten restraints are used to prevent the child from scratching or removing tubes. They are not typically used for venipuncture.
Choice C rationale
Mummy restraints are often used for infants during procedures like venipuncture. They allow the child to be wrapped securely while leaving one area exposed for the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice c. Sunken anterior fontanel.
Choice A rationale:
A heart rate of 162/min in a 2-month-old infant can be within the upper range of normal, especially if the infant is crying or agitated. While it is important to monitor, it is not the most critical finding in this context.
Choice B rationale:
A negative doll’s eye reflex (oculocephalic reflex) can indicate neurological issues, but it is not directly related to heart failure or the administration of furosemide.
Choice C rationale:
A sunken anterior fontanel indicates dehydration, which is a critical concern for an infant receiving furosemide, a diuretic that can lead to significant fluid loss. Dehydration can exacerbate heart failure and lead to severe complications.
Choice D rationale:
A potassium level of 5.1 mEq/L is slightly elevated but not immediately life-threatening. It requires monitoring and potential intervention but is not the most urgent issue compared to dehydration.
Monitoring for dehydration is crucial in infants on diuretics like furosemide, making the sunken anterior fontanel the priority finding.
Correct Answer is B
Explanation
Choice A rationale
Osteomyelitis is an infection of the bone, typically caused by bacteria. While it can occur as a complication of a fracture, it is not the most immediate concern within the first 24 hours after injury.
Choice B rationale
Compartment syndrome is a serious condition that involves increased pressure in a muscle compartment. It can lead to muscle and nerve damage and problems with blood flow. It can develop within hours of a severe injury like a fracture. Therefore, it is crucial to monitor for signs of compartment syndrome, such as severe pain, paleness, numbness, or decreased strength, in the first 24 hours after a fracture.
Choice C rationale
Volkmann ischemic contracture is a condition that can occur if there is prolonged or severe muscle ischemia (lack of blood flow) following a fracture. However, this condition is not typically seen within the first 24 hours after injury.
Choice D rationale
Renal calculi, or kidney stones, are hard deposits made of minerals and salts that form inside your kidneys. They are not a complication that would arise within the first 24 hours after a fracture.
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